World AIDS Day: Progress and Challenges
As a pediatrics resident in Harlem in the 1980s, Stephen Nicholas, MD, found himself in the epicenter of the mother-baby AIDS epidemic, an experience that shaped his career. Dr. Nicholas devoted himself to pediatric AIDS prevention and care, becoming a pioneer in the field. For World AIDS Day, he shares reflections on the epidemic's history and future, his work, and current comparisons between the Ebola and HIV/AIDS epidemics.
Dr. Nicholas is the P&S associate dean for admissions, director of the global health track for scholarly projects by P&S students, a professor of pediatrics and population & family health at CUMC, and director of the IFAP Global Health Program, which he established. IFAP introduced the first AIDS treatment in the Dominican Republic to prevent mother-to-child HIV transmission and subsequently played a central role in the creation of the country’s national AIDS program. In 2004 the program started the first family model of AIDS care in La Romana, D.R.
Tell us about your work in HIV/AIDS treatment and research. I came to New York in 1981 for my pediatric residency in a new primary care track, in which I would work at Babies Hospital (now the Morgan Stanley Children’s Hospital of New York Presbyterian) and Harlem Hospital. That month, the first report of AIDS in previously well homosexual men was published. At the time, I saw no connection between this terrifying new disease and the care of children. Within two years, however, the first pediatric AIDS cases were reported, and Harlem was the “epicenter” of the mother-baby AIDS epidemic. By 1987, nearly 5 percent of all pregnant women in central Harlem were HIV-infected.
With the support and guidance of Dr. Margaret Heagarty, the director of pediatrics at Harlem Hospital, I began work to establish a program for children with AIDS and their families. My colleagues Elaine Abrams and Wafaa El- Sadr played key roles in creating what became the Harlem Hospital Family Care Center, a model family AIDS program with significant research and clinical trials capacity.
Around half of all children with HIV in New York City needed foster care, because of parental drug addiction, illness, or death. A confluence of factors—fear that the children were contagious, a perception that they all were going to die, and the complexity of their needs—resulted in a lack of placement options for these children. Hospitals became the default repository for them (they were called “boarder babies with AIDS”).
I helped establish and then directed the Incarnation Children’s Center, the first transitional group home for children with HIV in New York City. It was relicensed as the only nursing home for chronically ill children with HIV. We also established an outpatient clinic and NIH-funded pediatric AIDS clinical trials sub-unit.
In 1999, I started the IFAP Global Health Program (now a division of the Department of Pediatrics) to support AIDS-related efforts in the Dominican Republic. In 2004, Elaine and Wafaa started the International Center for AIDS Care and Treatment Program (ICAP) at Mailman, which works primarily in sub-Sahara Africa. Harlem turned out to be a good training ground for our work in global health.
What changes have you seen in the field since you started your work? The progress has been amazing, beyond any reasonable expectation. With the advent of the so-called AIDS cocktails (highly active anti-retroviral therapy, or HAART), children with HIV stopped dying and started growing into adulthood. There’s been a more than 99 reduction in pediatric AIDS cases. Our oldest once-pediatric-patient at Harlem Hospital, born with HIV, will turn 35 this year. My HIV-infected patients—the ones who survived, and, mercifully, that turned out to be most of them—have now all aged out of pediatrics and into adult care. It’s an unexpected and highly satisfying way to become unemployed.
Most important, a clinical trial in the early 1990s showed that the rate of mother-to-baby HIV transmission can be substantially reduced by giving anti-retroviral therapy to HIV-infected pregnant women and their newborns. Without intervention, an HIV-infected pregnant woman has around a 40 percent risk (if she breastfeeds) or 25 percent risk (if she doesn’t) of having an HIV-infected baby. Today, with the use of prenatal HAART, transmission can be reduced to less than 1 percent.
From the beginning, AlDS has been a highly politicized disease. Getting pregnant women tested for HIV was a huge challenge. There was a bitter fight in New York over mandatory newborn HIV testing, but when it was legislated in 1996 (and then augmented by requirements for expedited HIV testing during labor and delivery), there was dramatic progress as a result. Today, 96 percent of pregnant women know their HIV status prior to delivery, and 99.7 percent of HIV-infected women and their infants receive anti-retroviral therapy.
The mother-baby HIV epidemic in New York State peaked in 1991. That year, approximately 600 HIV-infected babies were born. In 2013, two HIV-infected babies were born. This unprecedented progress sounds easy in the telling, but multiple complex factors underlie it. I teach an entire course about this at Mailman.
Can you describe the current state of the HIV epidemic and research? T The progress around pediatric AIDS should not be taken to mean that the HIV epidemic is over. Around 500 HIV-infected women still give birth annually in New York state. More than 1 million people in the United States have HIV infection, and about 1out of 6 of is unaware of the infection. Around 50,000 individuals are newly infected annually, 25 percent of whom are 13–24 years of age. Men who have sex with men remain at the highest risk. Minorities are still disproportionately affected by the HIV epidemic. Our work’s not over.
What, if any, are the gaps in the HIV/AIDS situation between poor and wealthier countries? Worldwide, AIDS is disproportionately about poverty, and HIV is transmitted predominantly heterosexually. Over the past decade, there has been remarkable scaling up of HIV diagnosis, prevention, care, and treatment in low- and middle-income countries, thanks to well-funded programs such as PEPFAR (the President’s Plan for AIDS Relief, started by George W. Bush); the Global Fund to Fight AIDS, Tuberculosis and Malaria; and many other governmental and nongovernmental partners.
Real progress has been made: New HIV cases have steadily declined, as have deaths from AIDS; more than 9 million individuals in low- and middle-income countries have been started on AIDS treatment; efforts to diagnose and treat pregnant HIV-infected women have been greatly increased; and the number of children born with HIV has decreased by 25 percent.
Exciting advances include a lowering of the treatment threshold, in recognition of the cost-effectiveness of “treatment as prevention”; an expansion of male circumcision, which reduces HIV transmission; and greater support for treating HIV co-morbidities, such as diabetes, cardiovascular disease, tuberculosis, and hepatitis C.
Africa continues to have the highest rate of AIDS, with 68 percent of new HIV infections and 72 percent of AIDS deaths. South Africa alone accounts for around 18 percent of the total number of people living with HIV.
The remaining challenges include overall deficiencies, in funding and structure, of the health care systems in most resource-poor countries. There are insufficient generic AIDS drugs, and when patients develop resistance to their treatment, there are limited options that are not prohibitively expensive. The diagnosis, management, treatment, and prevention of multi-drug-resistant tuberculosis and malaria also remain huge challenges.
How far do you think we are from a vaccine? I recently read a paper suggesting that despite the enormous challenges of developing an effective HIV vaccine, “researchers have made remarkable progress toward that goal in recent years.” Sadly, that’s misleading. The HIV virus inserts itself into a cell’s genome, constantly mutates, and, as though wearing Harry Potter’s “Cloak of Invisibility,” manages to escape immune recognition. Unfortunately, I think we’re probably years away from an effective vaccine. I hope I’m wrong.
We would like a vaccine; we would like a cure. Few of the diseases that kill most of us are curable, however, but they are treatable. The HIV/AIDS treatments work.There are more than 30 single and combination FDA-approved drugs, and many more are in development. They may have significant side effects and drug interactions, and there is the risk of viral resistance with poor adherence. But these treatments have brought many individuals back from the brink of death, into a productive life that is likely to be long.
The current Ebola epidemic has been compared to the AIDS epidemic. Why? Ebola is in many ways far more dramatic than AIDS, as its incubation period is short and the consequences are abrupt and deadly. The magnitude of AIDS was far greater, and it was happening right here, at home. But the hysteria, the politicization, the disproportionate effect on poor people with inadequate health care, the slow and muddled response (though in both instances, the CDC has been smart and heroic), and the tendency toward blame and stigmatization are all familiar. Yet there are selfless and risk-taking people like Dr. Craig Spencer to remind us why we went into medicine. I’m proud to be associated with him and proud that we both have a joint appointment in the Heilbrunn Department of Population and Public Health. He deserves our utmost respect.
Tell us more about IFAP's work in the Dominican Republic and progress in HIV transmission rate. The Domincan Republic’s national maternal HIV-transmission rate has fallen from 25 to 40 percent in 2000 to 4.1 percent in 2012. Despite being a province with one of the highest rates of HIV in the Caribbean, La Romana has had no HIV-infected infants born for the past two years.
Today, IFAP supports several programs, including summer internships for health sciences students, scholarly projects for medical student,; a one-year medical student global health research scholars program, medical student and resident clinical elective rotations at multiple international sites, and the new Dr. Edgar Housepian Global Health Lecture Series. The CUMC Newsroom recently posted an article about this work.